Continuum Coordinator (C2) Discharge Planner

Description

The Continuum Coordinator (C2) Discharge Planner assists with collaboratively managing the progression of patient’s care with the Clinical Care Manager, physician and health care team utilizing evidence based best practice guidelines. The C2 Discharge Planner engages the patient and care team in the joint management of key patient outcomes and transition to most appropriate post-acute setting. The C2 – Discharge Planner is a patient advocate who is focused on the “whole patient experience” not just the acute care episode. Ensures optimal communication and management of patient flow across the continuum. The C2-Dischage Planner serves as a resource to the staff, patients, and families.

Primary Duties

• Actively engages patient and family during the discharge process and provides educational resources regarding choice, cost and scope of services provided, i.e., Dialysis, Pharmaceutical, home infusion under the direction of senior staff.
• Facilitates referrals to home care agencies, rehabs, DME vendors, home infusion vendors and home lab, or other programs as directed by the Clinical Care Manager.
• Assists with prior approval/preauthorization from insurance for post acute care services.
• Proactively identifies and removes barriers by providing information and referral services/linkages to entitlement programs, insurance programs or other appropriate hospital resources as well as community-based organizations.
• Explains to patient/family the Medicare important notice, their appeal rights and 3-day qualifying hospital stay requirements for Sub Acute Rehabilitation coverage services if appropriate.
• Facilitates patient transfers to other healthcare organizations in accordance with hospital policies and all applicable State and Federal guidelines/ regulations and Joint Commission standards.
• Clearly documents discharge plan and provides appropriate information to post hospital care providers.
• Advocates for culturally competent care and appropriate literacy level.
• Escalates any patient quality concerns to Clinical Care Manager or unit leadership and attends Patient Safety & Quality reviews as needed.
• Reports all variances through established outcome management and quality improvement process.
• Verifies patient identification prior to discharge handoff to external providers.
• Identifies any avoidable days that contributed to increased length of stay and documents appropriately.
• Utilizes the teach back process to ensure patients/families are informed regarding their discharge plan.
• Identifies variances in care reasons and escalates Clinical Care Manager or local leadership.
• Serves as a role model in an ever-changing environment which supports the hospital mission.
• Participates in unit-based interdisciplinary meetings in a patient centric manner.
• Develops and mentors C2 Discharge Planning Staff as necessary.
• Fosters team’s ability to work together and achieve desired outcomes.
• Recognize the strength and expertise of all members to develop and implement the most patient centric plan.

Minimum Qualifications

• Associate's degree in health-related field
• Three years of experience in health-related field
• Working knowledge of discharge planning and community resources preferred

Mission Statement

We, St Joseph’s Health and Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities. Vision To be world-renowned for passionate patient care and outstanding clinical outcomes. Core Values In the spirit of good Stewardship, we heal by practicing Justice in fostering right relationships to promote common good, Reverence in honoring the dignity of every person, Excellence in expecting the best of ourselves and others; Integrity in being faithful to who we say we are.

Pay Range

Pay Range: $23.80 - $31.40 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.